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Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the functions of the nervous system and general health. It emphasizes manual therapy including spinal adjustment and other joint and soft-tissue manipulation. Traditionally, it is based on the premise that a vertebral subluxation or spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. Today, the progressive view examines the relationship between structure and function and its impact on neurological mechanisms in both health and disease.

Chiropractors usually obtain one of the following equivalent first professional degrees in chiropractic medicine (D.C. or D.C.M. or B.Chiro or M.Chiro). Chiropractors use a combination of treatments that are predicated on the specific needs of the individual patient. A chiropractor can develop and carry out a comprehensive treatment and management plan that can include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.

Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is practiced in more than 100 countries. Since its inception, chiropractic has been the subject of controversy within the profession and among the medical and scientific community, particularly regarding the metaphysical approach espoused by its founders and advocated by "straight" chiropractors. This same criticism may have been the catalyst that allowed some within the profession to emphasize primarily a neuromusculoskeletal approach in their educational curriculum, leading them away from the original metaphysical explanations of their predecessors towards more scientific ones.

Chiropractors have historically fallen into two main groups, "straights" and "mixers"; both groups contain recent off-shoots. Significant differences regarding scope of practice, claims made about spinal manipulation, and beliefs regarding professional integration, differentiate the various schools of thought and practice styles held within the profession.

Philosophy

Traditional and evidence-based chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to materialism. These opposing philosophies have been a source of debate since the time of Aristotle and Plato. Vitalism, the belief that living things contain an element that cannot be explained through matter, was responsible for legally and philosophically differentiating chiropractic from conventional medicine and thereby helping ensure professional autonomy. Chiropractic also retains elements of materialism, the belief that all things have explanations, which forms the basis of science. Evidence-based chiropractic balances this dualism by emphasizing both the tangible, testable principle that structure affects function, and the untestable, metaphorical recognition that life is self-sustaining. The chiropractor's purpose is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being of the person as a whole. Principles such as holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms form an important part of the philosophy of chiropractic"

Chiropractors can adopt or share vitalist, naturalist, or materialist viewpoints and emphasize a holistic, patient-centered approach that appreciates the multifactorial nature of influences (i.e. structural, chemical, and psychological) on the functioning of the body in health and disease and recognizes the dynamics and interplay between lifestyle, environment, and health. This holistic paradigm is also blended with a biopsychosocial approach, which is also emphasized in chiropractic care. In addition, chiropractors also retain naturopathic and naturalist principles that suggest decreased "host resistance" of the body facilitates the disease process and that natural interventions are preferable towards strengthening the host in its effort to optimize function and return to homeostasis. Chiropractic care primarily emphasizes manipulation and other manual therapies as an alternative than medications and surgery.

Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care. Chiropractic's claim to improve health by improving biomechanical and neural function by the manual correction of joint and soft tissue dysfunctions of the neuromusculoskeletal system differentiates it from mainstream medicine and other complementary and alternative medicine (CAM) disciplines, but is also rooted, in part, in osteopathy and eastern medicine interventions. All chiropractic paradigms emphasize the spine as their focus, but their rationales for treatment vary depending on their particular belief system.

The philosophy of chiropractic also stresses the importance of prevention and primarily utilizes a pro-active approach and a wellness model to achieve this goal. For some, prevention includes a concept of "maintenance care" that attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state. The objective is early identification of mechanical dysfunctions to prevent or delay permanent pathological changes.

In summary, the major premises regarding the philosophy of chiropractic include:

• Holism

• non-invasive, emphasizes patient's inherent recuperative abilities
• recognizes dynamics between lifestyle, environment, and health
• spine and health are related in an important and fundamental way, and this relationship is mediated through the nervous system.
• recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
• appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

• Conservatism

• balances the benefits against the risks of clinical interventions
• emphasizes non-invasive treatments to minimize risk with a preference to avoid surgery and medication
• recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
• prevents unnecessary barriers in the doctor-patient encounter

• Manual and biopsychosocial approaches

• strives toward early intervention, emphasizing timely diagnosis and treatment of reversible conditions before loss of functionality
• emphasizes a patient-centered model in which the patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health
• approach of improving health through influencing function through structure primarily via manual therapies

Treatment procedures

Spinal manipulation is the most common modality in chiropractic care. The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques, as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine. Spinal manipulation gained mainstream recognition during the 1980s (see History). In the U.S., chiropractors perform over 90% of all manipulative treatments and consider themselves to be expertly qualified providers of spinal adjustment, manipulation and other manual treatments.

Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anaesthesia. Typically, it is performed on patients who have failed to respond to other forms of treatment.

Schools of thought and practice styles

Common themes to chiropractic care include holistic, conservative and non-medication approaches via manual therapy. Still, significant differences exist amongst the practice styles, claims and beliefs between various chiropractors. Those differences are reflected in the varied viewpoints of multiple national practice associations.

Straight

Straight chiropractors are the oldest movement. They adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an Innate intelligence within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies. Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

Mixer

Mixer chiropractors are an early offshoot of the straight movement. This branch "mixes" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixers believe subluxation is one of the many causes of disease, and they incorporate mainstream medical diagnostics and employ myriad treatments including joint and soft tissue manipulation, electromodalities, physical therapy, exercise-rehabilitation and other complementary and alternative approaches such as acupuncture. In contrast to straight chiropractors, mixers generally want to be integrated into mainstream health care via integrative medicine.

Education, licensing, and regulation

Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and two in Canada, and an estimated 70,000 chiropractors in the USA, 6500 in Canada, 2500 in Australia, 2,381 in the UK, and smaller numbers in about 50 other countries.

Utilization and satisfaction rates

Chiropractic is the largest alternative medical profession in the U.S. The percentage of population that utilize chiropractic care at any given time generally fall into a range from 6% to 12% in the U.S. and Canada, with a global high of 20% in Alberta. The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints; most do so specifically for low back pain. Complementary and alternative medicine (CAM) practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention. Satisfaction rates are typically higher for chiropractic care compared to medical care, with quality of communication seeming to be a consistent predictor of patient satisfaction with chiropractors. Despite high patient satisfaction scores, utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient. The use of chiropractic is growing modestly; CAM as a whole is seeing wholesale increases. Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.

History

Chiropractic (also known as Chiropractic Medicine) was founded in 1895 by Canadian-American Daniel David Palmer in Davenport, Iowa, USA. D.D. Palmer gave the first spinal adjustment to a deaf janitor, Harvey Lillard, on September 18, 1895, reportedly resulting in a restoration of the man's hearing. Palmer hypothesized that manual manipulation of the spine could result in improved neurological function and health. Friend and Rev. Samuel Weed suggested combining the words cheiros and praktikos (meaning "done by hand") and chiropractic was born.

Vertebral subluxation

Palmer hypothesized that vertebral joint misalignments, which he termed "vertebral subluxations," interfered with the body's function and its inborn (innate) ability to heal itself. D.D. Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone (health) of the end organ. D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic. This concept was later expanded upon by his son, B.J. Palmer and was instrumental in providing the legal basis of differentiating chiropractic medicine from conventional medicine. In 1910, D.D. Palmer theorized that the nervous system controlled health:

"Physiologists divide nerve-fibers, which form the nerves, into two classes, afferent and efferent. Impressions are made on the peripheral afferent fiber-endings; these create sensations that are transmitted to the center of the nervous system. Efferent nerve-fibers carry impulses out from the center to their endings. Most of these go to muscles and are therefore called motor impulses; some are secretory and enter glands; a portion are inhibitory their function being to restrain secretion. Thus, nerves carry impulses outward and sensations inward. The activity of these nerves, or rather their fibers, may become excited or allayed by impingement, the result being a modification of functionality—too much or not enough action—which is disease."

The concept of subluxation remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades. In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, dogmatic beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community. This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic (for example, Palmer School of Chiropractic) still teaching the traditional/straight subluxation-based chiropractic, while others (for example, Canadian Memorial Chiropractic College) have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions but retains a holistic approach and an emphasis on manual therapy. As of 2005, the chiropractic subluxation was defined by the World Health Organization as "A lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity." "This definition is different from the current medical definition, in which subluxation is a significant structural displacement, and therefore visible on static imaging studies." According to a 2002 survey, 68% of chiropractors believed that "most diseases are caused by spinal malalignment," although only 30% agreed that "subluxation was the cause of many diseases."

Medical opposition

In 1899, a medical doctor in Davenport, USA, named Heinrich Matthey started a campaign against drugless practitioners. D.D. Palmer insisted that his techniques did not need the same courses or license as medical doctors, as his graduates did not prescribe drugs, perform surgery or evaluate laboratory diagnostics. However, in 1906, D.D. Palmer was convicted for practicing medicine without a license. In response, B.J. created the Universal Chiropractic Association (UCA) for the purpose of protecting its members by covering their legal expenses should they get arrested for practicing medicine.

Its first case came in 1907, when Shegataro Morikubo, DC was charged with unlicensed practice of osteopathic medicine in Wisconsin. Morikubo was freed using the defense that chiropractic philosophy was different from osteopathic philosophy. The victory reshaped the development of the chiropractic profession, which then marketed itself as a science, an art and a philosophy. This began a longstanding feud between chiropractors and medical doctors that would culminate in the mid 1980's in a landmark case, Wilk et al. vs American Medical Association (AMA). Until 1983, the AMA held that it was unethical for medical doctors to associate with an "unscientific practitioner", and labeled chiropractic "an unscientific cult". In 1984, Joseph Janse, DC, ND, attempted to describe the divide in chiropractic and medical philosophy regarding prevention and patient care:

"Unless pathology is demonstrable under the microscope, as in the laboratory or by roentgenograms, to them it does not exist. For years the progressive minds in chiropractic have pointed out this deficiency. With emphasis they have maintained the fact that prevention is so much more effective than attempts at a cure. They pioneered the all-important principle that effective eradication of disease is accomplished only when it is in its functional (beginning) phase rather than its organic (terminal) stage. It has been their contention that in general the doctor, the therapist and the clinician have failed to realize exactly what is meant by disease processes, and have been satisfied to consider damaged organs as disease, and to think in terms of sick organs and not in terms of sick people. In other words, we have failed to contrast disease with health, and to trace the gradual deteriorization along the downward path, believing almost that mild departures from the physiological normal were of little consequence, until they were replaced by pathological changes…"

Wilk et al. vs. American Medical Association

Chester A. Wilk, DC from Chicago initiated an antitrust suit against the AMA and other medical associations in 1976 - Wilk et al. vs AMA et al. The landmark lawsuit ended in 1987 when the US District Court found the AMA guilty of conspiracy and restraint of trade; the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated. The court recognized that the AMA had to show its concern for patients, but was not persuaded that this could not have been achieved in a manner less restrictive of competition, for instance by public education campaigns. A summary of the court's opinion concluded:

"Evidence at the trial showed that the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country."

On February 7, 1990, the AMA lost its appeal, and could no longer prevent medical physicians from collaborating with chiropractors.

Movement toward science

In 1975, chiropractors joined medical and scientific attendees in a workshop sponsored by the National Institutes of Health on the research status of spinal manipulation. In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched. in 1983 the JMPT published an article advocating "a scientific institution with some capability for research" and was considered the beginning of the scientific chiropractic movement . Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s.

Scientific investigation

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care. This work has focused on spinal manipulation therapy (SMT) independently from the underlying philosophy of chiropractic, with little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.

Effectiveness

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. Chiropractic care, like all medical treatment, benefits from the placebo response, and it is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect. Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality. Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference, a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.

Available evidence covers the following conditions:

• Low back pain. Opinions differ on the efficacy of SMT for nonspecific or uncomplicated low back pain. An authoritative 2004 review found that SMT or mobilization is no more or less effective than other interventions. A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care.

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain. An authoritative 2004 review found that SMT/mobilization is effective only when combined with other interventions such as exercise. A 2008 review found that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis. A 2007 review found that SMT and mobilization are effective for neck pain.

• Headache. An authoritative 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache. A 2006 review found no rigorous evidence supporting SMT or other manual therapies for tension headache.

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and a lack of higher-quality publications supporting chiropractic management of leg conditions. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions. Other reviews have found no evidence of benefit for baby colic, bedwetting, fibromyalgia, or menstrual cramps.

Safety

Chiropractic care in general is safe when employed skillfully and appropriately. Its primary therapeutic procedure, spinal manipulation, involves directed thrust to move a joint past its physiological range of motion without exceeding the anatomical limit. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications.

Spinal manipulation is associated with frequent, mild and temporary adverse effects, including new or worsening pain or stiffness in the affected region. They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours. Rarely, spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults and children. The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions. These strokes after manipulation appear to be unpredictable and are an inherent, idiosyncratic, and rare complication of cervical spine manipulation.

Absolute contraindications to spinal manipulation are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints. Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis. Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.

Vaccination

Although vaccination is one of the most cost-effective forms of prevention against infectious disease, it remains controversial within the chiropractic community. Most chiropractic writings on vaccination focus on its negative aspects, claiming that it is hazardous or ineffective. Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines. The American Chiropractic Association and the International Chiropractic Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease. The Canadian Chiropractic Association supports vaccination; surveys in Canada in 2000 and 2002 found that 40% of chiropractors supported vaccination, and that over a quarter opposed it and advised patients against vaccinating themselves or their children.

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